Section 4: Tarsal Coalitions

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Barnaby Fowler
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1 Case H (Figure 2): PedCat CBCT transverse plane reconstruction of right Lisfranc midfoot dislocation compared to normal left foot. Clinical Relevance of the PedCat Study: The weight bearing CBCT study provided the structural evidence to diagnose the patient with a Lisfrancs midfoot dislocation. The study aided in the diagnosis and was utilized for presurgical planning. Section 4: Tarsal Coalitions Case Study I: Calcaneo-Navicular and Cuboid-Navicular Coalition Clinical History: L.S. is a 70 year old female who has been asymptomatic her entire life. She went for a 2 mile walk on the soft sand at the beach. Her right foot became swollen following the walk. She presents complaining of right foot pain and swelling. X-Ray Findings: (Figures 1 & 2) The weight bearing AP, Medial Oblique and Lateral views demonstrate mild degenerative changes to the talo-navicular joint. There is a large anterolateral process of the calcaneus that extends upward and medial towards the navicular. These are suspicious findings suggestive of a calcaneo-navicular coalition. 21

2 Case I (Figure 1): Medial oblique radiograph of suspected calcaneo-navicular coalition. Case I (Figure 2): Lateral radiograph of suspected calcaneo-navicular coalition. 22

PedCat CBCT Findings: (Figures 3, 4 & 5) The sagittal, transverse, and frontal plane reconstruction views demonstrate a narrow and irregular gap between the anterolateral process of the calcaneus and

3 PedCat CBCT Findings: (Figures 3, 4 & 5) The sagittal, transverse, and frontal plane reconstruction views demonstrate a narrow and irregular gap between the anterolateral process of the calcaneus and the navicular consistent with the diagnosis of a fibrous or cartilaginous calcaneo-navicular coalition. More surprising, the transverse plane view identified a cuboid-navicular coalition. Case I (Figure 3): PedCat CBCT sagittal plane reconstruction of fibrous / cartilaginous calcaneo-navicular coalition. Case I (Figure 4): PedCat CBCT transverse plane reconstruction demonstrating fibrous / cartilaginous calcaneo-navicular coalition. 23

4 Case I (Figure 5): PedCat CBCT transverse plane reconstruction demonstrating calcaneo-navicular and cuboid-navicular coalitions. Clinical Relevance of the PedCat Study: The findings were significant as the calcaneo-navicular coalition was confirmed, but more importantly, without the PedCat study the cuboid-navicular coalition would not have been diagnosed. Case Study J: Talocalcaneal middle facet coalition Clinical History: 45 year old male presents complaining of medial foot and ankle pain. He has had very flat feet his entire life. Conservative care management included ice, NSAIDs, rest, custom foot orthotics and cortisone injections into an arthritic talonavicular joint. X-Ray Findings: AP, Medial Oblique and Lateral weight bearing views of both feet demonstrated talar head beaking / spurring consistent with the diagnosis of tarsal coalition. The medial oblique view ruled out calcaneonavicular coalition. There was a great deal of bony superimposition between the talus and calcaneus on the lateral view due to severely pronated feet. Thus a talocalcaneal coalition could not be ruled in or out. PedCat CBCT Findings (Figures 1 & 2): The 2-dimensional reconstruction views in the frontal, sagittal and transverse planes all demonstrate a fibrous or cartilaginous coalition of the middle facet of the subtalar joint (talocalcaneal). The 2-dimensional reconstruction views also demonstrate large bone cysts in the talar heads with talar head beaking and talonavicular joint degenerative joint disease. 24

5 Case J (Figure 1): PedCat CBCT sagittal plane reconstruction of middle facet talocalcaneal coalition. Case J (Figure 2): PedCat CBCT sagittal plane reconstruction of middle facet talocalcaneal coalition. 25

Clinical Relevance of the PedCat Study: Based upon the clinical exam and radiographs the clinical suspicion for tarsal coalition was elevated.

6 Clinical Relevance of the PedCat Study: Based upon the clinical exam and radiographs the clinical suspicion for tarsal coalition was elevated. A CT or MRI study was indicated to identify the tarsal coalition. The PedCat study successfully identified the coalition and the talar bone cysts. As an added benefit was the weight bearing status. The alignment of the foot bones, in a weight bearing position, is critical to pre-operative and intra-operative surgical planning. Section 5: Foot Bone Tumors Case K: Fourth Toe Enchondroma Clinical History: H.J. was referred for specialty care. She had been diagnosed by a radiologist with a pathologic 4 th toe fracture due to a suspected enchondroma. X-Ray Findings (Figure 1): The AP and Lateral digital (toe) x-rays demonstrate widening of the 4 th toe proximal phalangeal midshaft with thinning and fracture of the cortices. A radiolucent bone tumor is present with central calcification. Case K (Figure 1): AP radiograph of suspected enchondroma right 4 th toe. 26

Section 3: Foot Subluxations and Dislocations

Section 3: Foot Subluxations and Dislocations Case Study F: Lisfranc s Midfoot Dislocation Clinical History: J.K. a 28 year old female presents complaining of a painful right foot. She sustained an acute